A Cross-Cultural Comparison of ICD-11 Complex Posttraumatic Stress Disorder Symptom Networks in Austria, the United Kingdom, and Lithuania

Assessing complex PTSD and PTSD: validation of the German version of the International Trauma Interview (ITI)

Background: With the introduction of the ICD-11 into clinical practice, the reliable distinction between Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) becomes paramount. The semi-structured clinician-administered International Trauma Interview (ITI) aims to close this gap in clinical and research settings.Objective: This study investigated the psychometric properties of the German version of the ITI among trauma-exposed clinical samples from Switzerland and Germany.Method: Participants were 143 civilian and 100 military participants, aged M = 40.3 years, of whom 53.5% were male. Indicators of reliability and validity (latent structure, internal reliability, inter-rater agreement, convergent and discriminant validity) were evaluated. Confirmatory factor analysis (CFA) and partial correlation analysis were conducted separately for civilian and military participants.Results: Prevalence of PTSD was 30% (civilian) and 33% (military) and prevalence of CPTSD was 53% (civilians) and 21% (military). Satisfactory internal consistency and inter-rater agreement were found. In the military sample, a parsimonious first-order six-factor model was preferred over a second-order two-factor CFA model of ITI PTSD and Disturbances in Self-Organization (DSO). Model fit was excellent among military participants but no solution was supported among civilian participants. Overall, convergent validity was supported by positive correlations of ITI PTSD and DSO with DSM-5 PTSD. Discriminant validity for PTSD symptoms was confirmed among civilians but low in the military sample.Conclusions: The German ITI has shown potential as a clinician-administered diagnostic tool for assessing ICD-11 PTSD and CPTSD in primary care. However, further exploration of its latent structure and discriminant validity are indicated.

Compassion-Focused Therapy for the Treatment of ICD-11-Defined Complex Posttraumatic Stress Disorder

The most effective treatments for ICD-11-defined complex posttraumatic stress disorder (CPTSD) remain unknown. Further research is needed to determine whether such treatments for CPTSD are the same as or different from-or require integration with-existing gold standard treatments for posttraumatic stress disorder (PTSD). Individuals with CPTSD experience the hallmark symptoms of PTSD (i.e., reexperiencing symptoms, avoidance symptoms, and the pervasive sense of perceived threat) and pervasive disturbances in self-organization, including affective dysregulation, negative self-concept, and difficulties with interpersonal relationships. Compassion-focused therapy (CFT) is a transdiagnostic approach that was originally developed to treat shame and self-criticism. CFT helps individuals learn how to regulate their emotions, shift their emotional response style from shaming and self-critical to wise and understanding, and engage in more compassionate and rewarding patterns of relating to self and others. This article describes CFT's possible application in the treatment of CPTSD and delineates areas for future research.

A new approach to cultural scripts of trauma sequelae assessment: The sample case of Switzerland

BACKGROUND

The novel concept of cultural scripts of trauma sequelae captures culture-specific expressions of posttraumatic distress (e.g., cognitive, emotional, interpersonal, psychosomatic changes) and their temporal associations. Cultural scripts of trauma sequelae complement pan-cultural (etic) diagnoses, such as posttraumatic stress disorder (PTSD) and Complex PTSD, as well as the cultural syndromes concept.

OBJECTIVE

This study aimed to develop the cultural scripts of trauma inventory (CSTI) for German-speaking Switzerland and to explore temporal associations of script elements.

METHOD

Five semi-structured focus groups were conducted with psychotraumatologists (n = 8) and Swiss trauma survivors (n = 7). The interview schedule included open questions about different domains of potential posttraumatic changes (emotions, cognitions, worldviews, interpersonal relationships, body-related experiences, behavior, and growth). Data were analyzed using qualitative content analysis.

RESULTS

The Swiss CSTI includes 57 emic elements that represent salient trauma sequelae (30 conformed with a theoretically derived item pool, 27 were newly phrased). Temporal script associations were visualized in a network, whereby self-deprecation, the urge to function and overcompensate, and the urge to hide and endure suffering had the highest number of connections.

CONCLUSION

While many posttraumatic changes identified in the present work seem to mirror pan-cultural phenomena represented in the Complex PTSD concept (e.g., self-deprecation), others (e.g., urge to function and perform, urge to hide and endure suffering) may be prominently related to Swiss culture with its value orientations. Knowledge about cultural scripts of trauma sequelae may provide a culture-specific framework that can help to understand individual experiences of distress and enable mental health practitioners to administer culturally sensitive interventions. Pending further validation, the Swiss CSTI bears the potential to advance culture-sensitive assessment of trauma sequelae.

A network analysis of ICD-11 Complex PTSD, emotional processing, and dissociative experiences in the context of psychological trauma at different developmental stages

Objective

Traumatic experiences are a significant risk factor for psychological disturbances, including disorders such as complex posttraumatic stress disorder, emotion-processing problems, and trauma-related dissociative experiences. The present investigation examined the coexistence of these symptoms using a network analysis model.

Method

This study included a sample of 406 people referred to comprehensive health centers in Tehran from September to December 2023 with psychopathological syndromes. Variables were assessed using The International Trauma Questionnaire, International Measurement of Exposure to Traumatic Event checklist, Baker Emotional Processing Questionnaire, and Dissociative Experiences. A regularized partial correlation network and Glasso algorithm, in combination with Extended Bayesian information criteria, were applied to estimate the network structure.

Results

Signs of unprocessed emotions and disturbance in self-organization symptoms were the most important symptoms in the symptom network, forming strong connections with other nodes. Thereby, these two symptoms can be regarded as the most important clinical manifestations in the symptom network following traumatic experiences. Three distinct symptom communities were identified: the community of traumatic experiences (childhood, adolescence, adulthood), the community of dissociative experiences (amnesia, depersonalization/derealization, and absorption), and the community of emotional processing (suppression, unpleasant emotional experience, Signs of unprocessed emotions, avoidance, and emotional control, posttraumatic stress disorder symptoms and disturbance in self-organization symptoms). The strongest edges observed were between childhood trauma-adolescence trauma (0.473) in the community of traumatic experiences, between amnesia and depersonalization/derealization (0.644) in the community of dissociative experiences, and between disturbance in self-organization symptoms and unprocessed emotions (0.324) in the community of emotional processing, indicating the recurrent occurrence of these symptoms.

Conclusion

In this study, disturbance in self-organization symptoms was identified as the central psychopathologic symptom in individuals experiencing traumas at different developmental stages. It seems that adolescent trauma and not childhood trauma plays a more decisive role in the symptoms that a person manifests after traumatic experiences. Also, posttraumatic stress disorder symptoms and disturbance in self-organization symptoms were recognized in the cluster of emotional processing symptoms and can have substantial roles in prioritizing therapeutic measures.

Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment

Psychological birth trauma and childbirth-related posttraumatic stress disorder represent a substantial burden of disease with 6.6 million mothers and 1.7 million fathers or co-parents affected by childbirth-related posttraumatic stress disorder worldwide each year. There is mounting evidence to indicate that parents who develop childbirth-related posttraumatic stress disorder do so as a direct consequence of a traumatic childbirth experience. High-risk groups, such as those who experience preterm birth, stillbirth, or preeclampsia, have higher prevalence rates. The main risks include antenatal factors (eg, depression in pregnancy, fear of childbirth, poor health or complications in pregnancy, history of trauma or sexual abuse, or mental health problems), perinatal factors (eg, negative subjective birth experience, operative birth, obstetrical complications, and severe maternal morbidity, as well as maternal near misses, lack of support, dissociation), and postpartum factors (eg, depression, postpartum physical complications, and poor coping and stress). The link between birth events and childbirth-related posttraumatic stress disorder provides a valuable opportunity to prevent traumatic childbirths and childbirth-related posttraumatic stress disorder from occurring in the first place. Childbirth-related posttraumatic stress disorder is an extremely distressing mental disorder and has a substantial negative impact on those who give birth, fathers or co-parents, and, potentially, the whole family. Still, a traumatic childbirth experience and childbirth-related posttraumatic stress disorder remain largely unrecognized in maternity services and are not routinely screened for during pregnancy and the postpartum period. In fact, there are gaps in the evidence on how, when, and who to screen. Similarly, there is a lack of evidence on how best to treat those affected. Primary prevention efforts (eg, screening for antenatal risk factors, use of trauma-informed care) are aimed at preventing a traumatic childbirth experience and childbirth-related posttraumatic stress disorder in the first place by eliminating or reducing risk factors for childbirth-related posttraumatic stress disorder. Secondary prevention approaches (eg, trauma-focused psychological therapies, early psychological interventions) aim to identify those who have had a traumatic childbirth experience and to intervene to prevent the development of childbirth-related posttraumatic stress disorder. Tertiary prevention (eg, trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing) seeks to ensure that people with childbirth-related posttraumatic stress disorder are identified and treated to recovery so that childbirth-related posttraumatic stress disorder does not become chronic. Adequate prevention, screening, and intervention could alleviate a considerable amount of suffering in affected families. In light of the available research on the impact of childbirth-related posttraumatic stress disorder on families, it is important to develop and evaluate assessment, prevention, and treatment interventions that target the birthing person, the couple dyad, the parent-infant dyad, and the family as a whole. Further research should focus on the inclusion of couples in different constellations and, more generally, on the inclusion of more diverse populations in diverse settings. The paucity of national and international policy guidance on the prevention, care, and treatment of psychological birth trauma and the lack of formal psychological birth trauma services and training, highlight the need to engage with service managers and policy makers.

Examining accurate diagnosis of complex PTSD in ICD-11

BACKGROUND

Complex posttraumatic stress disorder (complex PTSD), the most frequently suggested new category for inclusion by mental health professionals, has been included in the Eleventh Revision of the World Health Organization's International Classification of Diseases (ICD-11). Research has yet to explore whether clinicians' recognition of the distinct complex PTSD symptoms predicts giving the correct diagnosis. The present study sought to determine if international mental health professionals were able to accurately diagnose complex PTSD and identify the shared PTSD features and three essential diagnostic features, specific to complex PTSD.

METHODS

Participants were randomly assigned to view two vignettes and tasked with providing a diagnosis (or indicating that no diagnosis was warranted). Participants then answered a series of questions regarding the presence or absence of each of the essential diagnostic features specific to the diagnosis they provided.

RESULTS

Clinicians who recognized the presence or absence of complex PTSD specific features were more likely to arrive at the correct diagnostic conclusion. Complex PTSD specific features were significant predictors while the shared PTSD features were not, indicating that attending to each of the specific symptoms was necessary for diagnostic accuracy of complex PTSD.

LIMITATIONS

The use of written case vignettes including only adult patients and a non-representative sample of mental health professionals may limit the generalizability of the results.

CONCLUSIONS

Findings support mental health professionals' ability to accurately identify specific features of complex PTSD. Future work should assess whether mental health providers can effectively identify symptoms of complex PTSD in a clinical setting.

Symptom structure of complex posttraumatic stress disorder among Chinese young adults with childhood trauma: a network analysis

BACKGROUND

The 11th revision of the World Health Organization's International Classification of Diseases (ICD-11) includes a new disorder, complex posttraumatic stress disorder (CPTSD), the diagnostic applicability of which has not been discussed sufficiently in Chinese culture. The network approach to psychopathology enables investigation of the structure of disorders at the symptom level, which allows for analysis of direct symptom interactions. The main objectives of the present study were to explore CPTSD symptom structure and identify key symptoms in CPTSD among young adults in China.

METHODS

The present study collected a large, stratified sample of Beijing university students (1368), ranging from 18 to 25 years old, the majority of whom (65.4%) were female. CPTSD symptoms were assessed using the International Trauma Questionnaire (ITQ). A regularized partial correlation network and Bayesian network were applied to estimate the network structure and the upstream symptoms of CPTSD, respectively.

RESULTS

The regularized partial correlation network showed that the high central symptoms were feelings of failure and hypervigilance, while the bridge symptom between posttraumatic stress disorder (PTSD) and disturbance in self-organization (DSO) domains was long-term upset. The Bayesian network showed that external avoidance and hypervigilance symptoms were upstream in CPTSD symptoms.

CONCLUSIONS

Hypervigilance is a central symptom that can be predictive of other symptoms of CPTSD. While feeling of failure is also a highly central symptom, it may be influenced by other symptoms. In the diagnosis and intervention of CPTSD, more attention should be given to hypervigilance symptoms.

Sex Differences in Complex Posttraumatic Stress Disorder Network among Chinese Young Adults

Evidence suggests that sex differences commonly occur in trauma-related disorders. The current study aims to explore sex differences in complex posttraumatic stress disorder (CPTSD) symptom networks among Chinese young adults with childhood trauma. The current study utilized a representative sample of college students in Beijing and included 1416 participants (409 men and 907 women) who had childhood trauma experience. CPTSD symptoms were evaluated using the International Trauma Questionnaire. Regularized partial correlation network analysis and Bayesian network analysis were used to estimate the network structure and possible causality of CPTSD symptoms for both sexes. Male and female CPTSD symptom networks had differences in strength centrality and bridge centrality. Nightmares and feelings of failure had the highest strength centrality, and long-term upset and nightmares had the highest bridge centrality for men. Hypervigilance and feelings of failure had the highest strength centrality, and long-term upset and exaggerated startle response had the highest bridge centrality for women. The current study provides the first evidence of sex differences in the CPTSD symptom network among Chinese young adults with childhood trauma. Young men and women differed in highly central symptoms, which may speak to sex specificity in the main manifestations of CPTSD symptoms.

The relationship of posttraumatic stress disorder and developmental trauma disorder with childhood psychopathology: A network analysis

OBJECTIVE

Potentially traumatic experiences are a major risk factor for mental disorders in children and adolescents. Posttraumatic psychopathology includes trauma-specific disorders such as posttraumatic stress disorder (PTSD) as well as other psychiatric disorders. Developmental Trauma Disorder (DTD) has been proposed as a developmentally sensitive diagnosis. We aimed to further illuminate the co-occurrence of psychiatric conditions with DTD and PTSD.

METHOD

In a convenience sample of families of 507 children and adolescents (mean age = 12.11 years old, SD = 2.92; 48.5% female), we assessed DTD, PTSD, and screened for psychiatric disorders. We estimated network models including DTD, PTSD and ten psychiatric conditions.

RESULTS

We found that DTD and PTSD share both common and differential comorbidity features on disorder-, domain-, and symptom-level. The differential comorbidity patterns of the DTD and PTSD domains placed DTD close to both externalizing and internalizing psychopathology while PTSD was primarily linked to internalizing conditions.

CONCLUSIONS

Our study provides evidence for the complex clinical presentation of posttraumatic psychopathology over and above PTSD in children. DTD and PTSD provide useful and distinct diagnostic categories for children who are also experiencing internalizing conditions, and DTD may be especially relevant for children who are experiencing externalizing psychopathology.

An exploration of gender and prolonged grief symptoms using network analysis

BACKGROUND

Gender has been proposed as a potentially important predictor of bereavement outcomes. The majority of research in the field has explored this issue by examining gender differences in global grief severity. Findings have been mixed. In this study, we explore potential gender differences in grief using network analysis. This approach examines how individual symptoms relate to and reinforce each other, and so offers potential to shed light on novel aspects of grief expression across genders.

METHOD

Graphical lasso networks were constructed using self-report data from 839 spousally bereaved older participants (584 female, 255 male) collected at 2- and 11- months post-bereavement. Edge strength, node strength and global network strength were compared to identify similarities and differences between gender networks across time.

RESULTS

At both time points, the strongest connection for both genders was from yearning to pangs of grief. Yearning, pangs of grief, acceptance, bitterness and shock were prominent nodes at time 1. Numbness and meaninglessness emerged as prominent nodes at time 2. Males and females differed in the relative importance of shock at time 1, and the female network had greater overall strength than the male network at time 2.

CONCLUSIONS

This study identified many similarities and few differences in the relationships between prolonged grief symptoms for males and females. Findings suggest that future studies should examine alternate sources of variation in grief outcomes. Limitations are discussed.

The boundaries between complex posttraumatic stress disorder symptom clusters and post-migration living difficulties in traumatised Afghan refugees: a network analysis

BACKGROUND

Psychological distress due to the ongoing war, violence, and persecution is particularly common among Afghan asylum seekers and refugees. In addition, individuals face a variety of post-migration living difficulties (PMLDs). Complex posttraumatic stress symptoms are among the most common mental health problems in this population, and were associated with the overall burden of PMLDs. The complex interplay of posttraumatic symptoms has been investigated from a network perspective in previous studies. However, individuals are embedded in and constantly react to the environment, which makes it important to include external factors in network models to better understand the etiology and maintaining factors of posttraumatic mental health problems. PMLDs are a major risk factor for posttraumatic distress and considering their impact in interventions might improve response rates. However, the interaction of these external factors with posttraumatic psychopathological distress is not yet fully understood. Thus, we aimed to illuminate the complex interaction between PMLDs and CPTSD symptom clusters.

OBJECTIVE

The main objective is the exploration of the network structure and the complex interplay of ICD-11 CPTSD symptom clusters and distinct forms of PMLDs.

METHOD

The symptom clusters of CPTSD and PMLDs were collected within a randomised controlled trial among 93 treatment-seeking Afghan asylum seekers and refugees via a fully structured face-to-face and interpreter assisted interview. Using a network analytical approach, we explored the complex associations and network centrality of the CPTSD symptom clusters and the PMLD factors: discrimination & socio-economical living conditions, language acquisition & barriers, family concerns, and residence insecurity.

RESULTS

The results suggest direct links within and between the constructs (CPTSD, PMLD). Almost all PMLD factors were interrelated and associated to CPTSD, family concerns was the only isolated variable. The CPTSD symptom cluster re-experiencing and the PMLD factor language acquisition & barriers connected the two constructs. Affective dysregulation had the highest and avoidance the lowest centrality.

CONCLUSIONS

Re-experiencing and affective dysregulation have the strongest ties to PMLDs. Thus, these domains might explain the strong association of posttraumatic psychopathology with PLMDs and, consequently, prioritization of these domains in treatment approaches might both facilitate treatment response and reduce burden caused by PMLDs.

Neural processes during response inhibition in complex posttraumatic stress disorder

BACKGROUND

A common feature of complex posttraumatic stress disorder (CPTSD) is impulsivity. Despite the importance of this characteristic in functional difficulties in CPTSD, little is known about its mechanisms. The aim of this study was to identify the distinctive neural profile of CPTSD during attempted inhibition.

METHODS

The present study examined functional alterations in neural networks involved in inhibitory control across functional magnetic resonance imaging (fMRI) and electroencephalogram (EEG) paradigms in CPTSD (n = 30), PTSD (n = 40), and healthy control (n = 40) participants who completed a Go/NoGo response inhibition task during separate fMRI and EEG sessions. Brain activations were calculated during the NoGo trials relative to the baseline to evaluate response inhibition functioning.

RESULTS

There was reduced bilateral thalamic activation in participants with CPTSD relative to PTSD and controls during inhibition trials, but no activation differences between PTSD and controls for this brain region. There were no differences in functional connectivity between the thalamus and other regions involved in cognitive control between groups. No differences were observed between groups on EEG responses.

CONCLUSIONS

These findings provide initial evidence of aberrant functioning in the neurocircuitry of inhibitory control, involving the thalamus, in CPTSD. This evidence suggests that CPTSD is distinguished from PTSD by impaired neural processes implicated in response inhibition.

The Italian Version of the International Trauma Questionnaire: Symptom and Network Structure of Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder in a Sample of Late Adolescents Exposed to a Natural Disaster

The 11th revision of the International Classification of Diseases has endorsed substantial changes in Post-Traumatic Stress Disorder (PTSD) and has introduced Complex PTSD (cPTSD). The objective of this study was to assess the symptom and network structure of PTSD and cPTSD using the International Trauma Questionnaire- Italian version (ITQ) and the prevalence of PTSD and cPTSD in a community sample of late adolescents enriched with exposure to a destructive earthquake. A 1,010 high school students participated to the study. Confirmatory Factor Analysis supports that a six first-order correlated factors was the best fitting model of ICD-11 PTSD/cPTSD. The network analysis supports a clear separation between core PTSD symptoms and disturbances in self-organization (DSO) symptoms, avoidance, and negative self-concept were the most central items. The prevalence of PTSD and cPTSD was 9.11 and 4.06%, respectively. Female participants reported higher rates of both PTSD and cPTSD. This is the first study to report on ICD-11 PTSD and cPTSD rates on an Italian adolescence community sample. Consistent with other community samples, we found higher rates of PTSD compared to cPTSD. The results confirmed the factorial validity of the ITQ. The network structure highlights the importance of negative self-concept in cPTSD and avoidance in PTSD.

The Network Structure of ICD-11 Disorders Specifically Associated with Stress: Adjustment Disorder, Prolonged Grief Disorder, Posttraumatic Stress Disorder, and Complex Posttraumatic Stress Disorder

INTRODUCTION

The ICD-11 includes a new grouping for "disorders specifically associated with stress" that contains revised descriptions of posttraumatic stress disorder (PTSD) and adjustment disorder (AjD) and new diagnoses in the form of complex PTSD (CPTSD) and prolonged grief disorder (PGD). These disorders are similar in that they each require a life event for the diagnosis; however, they have not yet been assessed together for validity within the same sample. We set out to test the distinctiveness of the four main ICD-11 stress disorders using a network analysis approach.

METHODS

A population-based, cross-sectional design. A nationally representative sample of adults from the Republic of Ireland aged 18 years and older (N = 1,020) completed standardized measures of PTSD, CPTSD, AjD, and PGD. A network analysis was conducted at the symptom level. Outcome measures included the International Trauma Questionnaire, the Inventory of Complicated Grief, and the International Adjustment Disorder Questionnaire.

RESULTS

Consistent with the taxonomic structure of the ICD-11, our results showed that although the four conditions clustered independently at the disorder level, the specific symptoms of PTSD, CPTSD, PGD, and AjD clustered together very strongly but more strongly than with symptoms of the other disorders. The majority (61%) of the variation in each symptom could be explained by its neighboring symptoms. The strongest transdiagnostically connecting symptom was "startle response."

DISCUSSION/CONCLUSION

Mental health professionals caring for people who have experienced a range of stressors and traumatic life events can be confident in diagnosing these conditions that have clear diagnostic boundaries. Interventions addressing stress-associated disorders should be based on diagnostic assessment to ensure close fit between symptoms and treatment.

Trauma exposure and factors associated with ICD-11 PTSD and complex PTSD in adolescence: a cross-cultural study in Japan and Lithuania

Aims

Cross-cultural studies of posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) based on ICD-11 diagnostic criteria are scarce, especially in adolescence. The study aimed to evaluate the trauma exposure, prevalence and factors associated with PTSD and CPTSD in general populations of adolescents in Lithuania and Japan.

Methods

The study sample comprised 1746 adolescents from Lithuania (n = 832) and Japan (n = 914), 49.8% female. The mean age of study participants was 15.52 (s.d. = 1.64), ranging from 12 to 18 years. ICD-11 posttraumatic disorders were assessed using the International Trauma Questionnaire – Child and Adolescent version (ITQ-CA).

Results

More than half of the adolescents in a total sample (61.5%) reported exposure to at least one traumatic event in their lifetime, 80.0% in Lithuania and 44.6% in Japan, with a higher prevalence of interpersonal trauma in Lithuania and more natural disaster exposure in Japan. The prevalence of PTSD was 5.2% (95% CI 3.8–6.9%) and 2.3% (95% CI 1.4–3.5%), CPTSD 12.3% (95% CI 10.1–14.7%) and 4.1% (95% CI 2.9–5.5%) in Lithuanian and Japanese samples, respectively. Cumulative trauma exposure, female gender, loneliness and financial difficulties in family predicted both PTSD and CPTSD in the total sample. Loneliness discriminated CPTSD v. PTSD in both Lithuanian and Japanese samples.

Conclusions

This cross-cultural study is among the first which reported different patterns of trauma exposure in Asian Japanese and Lithuanian adolescents in Europe. Despite differences in trauma exposure and PTSD/CPTSD prevalence, we found similar predictors in both studies, particularly the importance of cumulative trauma exposure for PTSD/CPTSD, and social interpersonal factors for the risk of CPTSD. The study supports the universality of traumatic stress reactions to adverse life experiences in adolescence across cultures and regions and highlights different levels of traumatisation of adolescents in various countries.

Item response model validation of the German ICD-11 International Trauma Questionnaire for PTSD and CPTSD

Background

In the 11th revision of the International Classification of Diseases (ICD-11) posttraumatic stress disorder (PTSD) and the complex variant (CPTSD) were newly conceptualised. The International Trauma Questionnaire (ITQ) was developed as a brief self-report measure to screen for both disorders. The English original version has been rigorously tested and presents convincing psychometric properties. The aim of the current study was to validate the German version by means of item response theory (IRT).

Method

This is a secondary analysis of a representative, trauma-exposed adult sample from the German general population (N = 500). 1- and 2-parameter logistic IRT models (i.e. examination on an item level), diagnostic rates and confirmatory factor analyses were calculated.

Results

All items showed good model fit and acceptable to good performance aligning with the items of the English original except for item C1 (Long time to calm down) which had a high endorsement rate and a low discriminatory power yielding low information gain. CPTSD diagnostic rate of 3.2% was lower than in comparable literature. Confirmatory factor analysis deemed the six first-order, two second-order factors model superior.

Conclusion

Measurement and factorial validity of the German version of the ITQ was confirmed. The German translation matches the English original in most psychometric properties and can thus be used for research and clinical practice.

Fatalism and ICD-11 CPTSD and PTSD diagnoses: results from Nigeria, Kenya & Ghana

Background

Existing research on post-traumatic sequelae suggests a positive association between fatalism and symptoms of post-traumatic stress disorder (PTSD). However, the associations between fatalism and the new ICD-11 diagnosis of complex PTSD (CPTSD) have never been explored before.

Objective

The current study explored the association between fatalism and PTSD and CPTSD in samples from three African countries.

Methods

A total of 2,524 participants from Nigeria (n = 1018), Kenya (n = 1006), and Ghana (n = 500) completed measures of fatalism (non-judgemental fatalism, current fatalism, pessimistic fatalism, prospective fatalism) and the International Trauma Questionnaire (ITQ). A combination of a multinomial regression and path analysis was used to identify fatalism predictors of PTSD and CPTSD versus no diagnosis, and CPTSD versus PTSD, adjusted for demographic variables and trauma exposure.

Results

While PTSD was not predicted by any of the fatalism types, compared to no diagnosis, CPTSD was significantly predicted by pessimistic, non-judgemental and current fatalism, both compared to no diagnosis and PTSD.

Conclusions

The results broaden the knowledge on potential correlates of the new diagnosis of CPTSD. Addressing fatalistic beliefs by empowering people to think that they can choose their fate should be further explored as a possible target for intervention in the treatment of CPTSD.

Unraveling specifics of mental health symptoms in war survivors who fled versus stayed in the area of conflict using network analysis

BACKGROUND

War survivors often report symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and somatization. Hence, understanding symptom constellations among different populations of war survivors is critical.

METHODS

Using the network approach to psychopathology, we examined symptom centrality for these conditions in war survivors from Balkan countries who had stayed in the area of former conflict compared to those individuals from Balkan countries who had fled to Western European countries (N = 4,167) with the Impact of Events Scale-Revised and the Brief Symptom Inventory. We further compared networks for war survivors who met criteria for PTSD-diagnosis (assessed with the MINI-International Neuropsychiatric Interview) to those without PTSD-diagnosis.

RESULTS

Globally, networks were similar across the groups, whereas specific differences emerged in symptom centrality. More consistencies were found between PTSD and Western country networks, which may be partially explained by a higher prevalence of PTSD in those who had fled to Western European than in those who had stayed in the Balkan countries.

LIMITATIONS

Given the cross-sectional nature of our data, the directionality of edges in our networks remains unclear. Further, higher levels of trauma exposure and symptom severity in Western country participants may have confounded results.

CONCLUSIONS

The PTSD findings are in line with previous research on PTSD symptoms. They further provide novel insights into depressive, anxiety, and somatization symptoms in survivors of war. These findings need to be substantiated and call for future intervention studies that test the effects of targeting central symptoms we identified in our study.

The interpersonal implications of PTSD and complex PTSD: The role of disturbances in self-organization

BACKGROUND

In the aftermath of trauma not only the primary traumatized survivors' mental health is affected but often also their significant others. The current study explores the specific associations of ICD-11 symptoms of posttraumatic stress disorder (PTSD) and disturbances in self organization (DSO) for secondary traumatic stress and dyadic adjustment among both spouses.

METHODS

Male Israeli veterans and their wives (N = 216) were assessed 30 years after the war. Primary PTSD/DSO symptoms of the veterans and secondary posttraumatic stress symptoms (secondary PTSS)/DSO of the wives were assessed. Actor Partner Independence Modelling (APIM) evaluated the differential effects of PTSD and DSO for trauma transmission and dyadic adjustment.

RESULTS

While veterans' primary PTSD only related to secondary PTSS of the wives, the veterans' DSO predicted the wives' secondary PTSS as well as DSO. Moreover, the APIM revealed that the primary and secondary DSO of both partners were associated with dyadic adjustment while their PTSD symptoms were not.

LIMITATIONS

The cross-sectional data did not allow to identify directional or causal effects and DSO symptoms were not assessed with an ICD-specific instrument as such scales did not exist at the time of data collection.

CONCLUSIONS

ICD-11 DSO symptoms seem to drive the transmission of posttraumatic stress among spouses to a more significant extent than PTSD symptoms. As DSO are also strongly implicated in decreased dyadic adjustment, they are valuable targets for couple therapy after one spouse experienced severe trauma, both in order to prevent interpersonal trauma transfer as well as to enhance dyadic adjustment.

Differences between ICD-11 PTSD and complex PTSD on DSM-5 section III personality traits

Background: The formulations of post-traumatic stress disorder (PTSD) and the newly included disorder complex PTSD (CPTSD) in the 11th edition of the International Classification of Diseases (ICD-11) have not been evaluated on a broad range of maladaptive personality traits. Objective: The aim of this study was to evaluate ICD-11 PTSD and CPTSD on maladaptive personality traits. Method: In a cross-sectional study of 106 Danish outpatients with ICD-10 PTSD, we used the International Trauma Questionnaire (ITQ) to identify patients with either ICD-11 PTSD or CPTSD (N = 84). We utilized the Personality Inventory for DSM-5 (PID-5) from the alternative model of personality disorders in DSM-5, section III, to evaluate personality trait differences between ICD-11 PTSD and CPTSD. Furthermore, PID-5 was also used to investigate relationships between personality traits and ICD-11 PTSD/CPTSD symptom clusters. The Life Event Checklist was used to assess traumatic experiences, and the MINI International Neuropsychiatric Interview was applied to assess comorbidity. Results: Patients with ICD-11 PTSD or CPTSD had elevated scores on personality traits indicative of internalizing psychopathology. However, higher impairment levels of the trait domains Negative Affectivity (d= 0.75) and Psychoticism (d = 0.80) discriminated patients with ICD-11 CPTSD from patients with PTSD. The PID-5 trait domain Detachment was moderately positively correlated to most of the ITQ symptom clusters and, the ITQ Negative Self-concept symptom cluster showed a relatively high number of significant correlations across all the PID-5 trait domains and facets. The PID-5 domain Negative Affectivity and almost all the encompassing facets were significantly correlated with DSO symptom clusters. Conclusions: The findings demonstrate the relevance of applying dimensional assessment of personality features to study the psychopathology of ICD-11 PTSD and CPTSD and potential differences. The results suggest that CPTSD is a more debilitating disorder than PTSD considering the severity of the personality features.

Comparing the network structure of ICD-11 PTSD and complex PTSD in three African countries

BACKGROUND

Symptom network analysis has become an essential tool for researchers and clinicians investigating the structure of mental disorders. Two methods have been used; one relies on partial correlations, and the second relies on zero order correlations with forced-directed algorithm. This combination was used to examine symptom connections for ICD-11 Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD) as the symptoms for these disorders have been known to be organized in a multi-dimensional and hierarchical fashion. We aimed to examine whether networks of ICD-11 CPTSD symptoms reproduced across samples from three African countries.

METHODS

We produced network models based on data from 2524 participants in Nigeria (n = 1018), Kenya (n = 1006), and Ghana (n = 500). PTSD and CPTSD symptoms were measured using the International Trauma Questionnaire (Cloitre et al., 2018).

RESULTS

The CPTSD network analysis using force-directed method alongside partial correlations based on Gaussian Graphical Models (GGM) revealed the multidimensional-hierarchal structure of CPTSD. The within-cluster symptoms of Disturbances in Self Organization (DSO) and PTSD were strongly correlated with each other in all networks, and the cross-cluster symptoms were lower. The most central symptom was 'feelings of worthlessness', a symptom of Negative Self-Concept that is part of the CPTSD cluster. The networks were very similar across the three countries.

CONCLUSIONS

Findings support the ICD-11 model of PTSD and CPTSD in three African countries.

Evidence of distinct profiles of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD in a South African sample

Background: Both post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD) have been included in the 11th edition of the International Classification of Diseases (ICD-11). Although the validity of CPTSD has been controversial, a growing number of studies support the distinction between PTSD and CPTSD. However, the majority of this research has originated in high-income countries (HICs), whereas the prevalence of trauma experience associated with PTSD/CPTSD diagnosis is significantly higher in low- and middle-income countries (LMICs). Objective: This study assessed whether a sample from an LMIC setting produced distinct classes that reflect ICD-11 criteria for PTSD and CPTSD. Furthermore, this study investigated whether childhood trauma distinguished between PTSD and CPTSD. Method: International Trauma Questionnaire responses from a sample of South African university undergraduates were used as indicator variables in a latent class analysis (LCA). Chi-squared tests of independence and Kruskal-Wallis H tests were used to assess between-class differences. Results: The LCA identified four distinct classes: a PTSD class with elevated symptoms of PTSD, but low endorsement of disturbances in self-organization (DSO; symptoms that are specific to CPTSD); a CPTSD class with elevated symptoms of PTSD and DSO; a DSO class with low symptoms of PTSD, but elevated symptoms of DSO; and a Low class with low endorsements on all symptoms. Regarding childhood trauma, participants in the CPTSD class had more severe childhood abuse and neglect, specifically emotional abuse and neglect, than participants in the PTSD class. Conclusions: Findings were consistent with the distinction between PTSD and CPTSD symptom profiles in the ICD-11. Our findings support a similar qualitative distinction between PTSD and CPTSD in our LMIC context, as previously reported in HICs. This distinction is especially relevant in LMICs because of the significant number of individuals vulnerable to these disorders.

Traumatic experiences, ICD-11 PTSD, ICD-11 complex PTSD, and the overlap with ICD-10 diagnoses

OBJECTIVES

This study investigated the frequency of traumatic experiences, prevalence rates of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD), and overlap with ICD-10 classified disorders in outpatient psychiatry.

METHOD

Overall, 165 Danish psychiatric outpatients answered the International Trauma Questionnaire, the Life Event Checklist, and the World Health Organization Well-being Index. ICD-10 diagnoses were extracted from the hospital record. Chi-square analysis, t-tests, and conditional probability analysis were used for statistical analysis.

RESULTS

Nearly, all patients (94%) had experienced at least one traumatic event. CPTSD (36%) was more common than PTSD (8%) and had considerable overlap with ICD-10 affective, anxiety, PTSD, personality, adjustment and stress-reaction disorders, and behavioural and emotional disorders with onset usually occurring in childhood and adolescence. ICD-11 PTSD overlapped with ICD-10 anxiety, PTSD, adjustment and stress-reaction disorders, and behavioural and emotional disorders with onset usually occurring in childhood and adolescence. A subgroup of patients with ICD-10 PTSD (23%) did not meet criteria for ICD-11 PTSD or CPTSD.

CONCLUSION

Traumatic experiences are common. ICD-11 CPTSD is a highly prevalent disorder in psychiatric outpatients. One quarter with ICD-10 PTSD did not meet criteria for either ICD-11 PTSD or CPTSD. PTSD and CPTSD had considerable overlap with ICD-10 disorders.

Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: response to Achterhof et al., (2019) and Ford (2020)

This letter to the editor responds to a recent EJPT editorial and following commentary which express concerns about the validity of the ICD-11 complex PTSD (CPTSD) diagnosis. Achterhof and colleagues caution that latent profile analyses and latent class analyses, which have been frequently used to demonstrate the discriminative validity of the ICD-11 PTSD and CPTSD constructs, have limitations and cannot be relied on to definitively determine the validity of the diagnosis. Ford takes a broader perspective and introduces the concept of 'cPTSD' which describes a wide ranging set of symptoms identified from studies related to DSM-IV, DSM-V and ICD-11 and proposes that the validity of the ICD-11 CPTSD is in question as it does not address the multiple symptoms identified from previous trauma-related disorders. We argue that ICD-11 CPTSD is a theory-driven, empirically supported construct that has internal consistency and conceptual coherence and that it need not explain nor resolve the inconsistencies of past formulations to demonstrate its validity. We do agree with Ford and with Achterhof and colleagues that no one single statistical process can definitively answer the question of whether CPTSD is a valid construct. We reference several studies utilizing many different statistical approaches implemented across several countries, the overwhelming majority of which have supported the validity of ICD-11 as a unique construct. We conclude with our own cautions about ICD-11 CPTSD research to date and identify important next steps.

Commentary on the Special Issue on Network Analysis: Assessment, Intervention, Theory, and the Nature of Reality: Actualizing the Potential of Network Perspectives on Posttraumatic Stress Disorder

This commentary on the Journal of Traumatic Stress special issue on network analysis explores the network perspective on posttraumatic stress disorder (PTSD), emphasizing the advances in research made in this collection of articles. The commentary is organized around the following themes related to actualizing the perspective's methodological, assessment, and intervention potential and the potential shift in the theoretical underpinnings of mental disorders that networks models imply. First, extant data using network analysis suggest that reactions to traumatic stress are more complicated than once thought but that this complexity does not mean efficient, relatively simple heuristics to aid assessment and intervention do not exist. Attention to methodological issues in symptom assessment may help move this aspect of the research forward. Second, the extant research is largely correlational and has not yet established causal linkages, although temporal associations underlying network models are being identified. Prospective and intervention studies employing network analysis are critical. Third, the network perspective of PTSD symptoms may advance research on the mechanisms of risk and resilience (e.g., neurodevelopmental, cognitive behavioral, emotional, and social models) by helping link symptoms to theoretical causal processes. A developmental framework that views the effect of traumatic stress in terms of temporal cascades of reactions with both negative and potentially positive cognitive, behavioral, social, and emotional outcomes fits the network analysis model. Fourth, network models call into question some of the fundamental assumptions underlying the conceptualization of mental disorders, leaving several ontological questions and implications currently unanswered; research examining the implications of the new assumptions is needed.

Introduction to the Special Issue: Network Analysis of Traumatic Stress

Network analysis has emerged as a promising new statistical methodology for traumatic stress studies. The present special issue of the Journal of Traumatic Stress amalgamates the reports of 10 studies that employed network analysis to further the field's understanding of traumatic stress. The current issue includes reports of network analyses that sought to better understand the impact of different kinds of traumatic events, including childhood and gender-based trauma exposure, on PTSD symptomatology as defined under the DSM-5 and ICD-11, and examined the relation between PTSD symptoms and trauma-related dissociative experiences as well as the impact of psychological treatment on trauma recovery. A variety of research designs from a diverse group of international samples were employed, including concurrent, longitudinal, experience-sampling, and treatment outcome studies. Finally, a commentary on the articles included in this special issue was provided by Dr. Carl Weems.

The replicability and generalizability of internalizing symptom networks across five samples

The popularity of network analysis in psychopathology research has increased exponentially in recent years. Yet, little research has examined the replicability of cross-sectional psychopathology network models, and those that have used single items for symptoms rather than multiitem scales. The present study therefore examined the replicability and generalizability of regularized partial correlation networks of internalizing symptoms within and across 5 samples (total N = 2,573) using the Inventory for Depression and Anxiety Symptoms, a factor analytically derived measure of individual internalizing symptoms. As different metrics may yield different conclusions about the replicability of network parameters, we examined both global and specific metrics of similarity between networks. Correlations within and between nonclinical samples suggested considerable global similarities in network structure (rss = .53-.87) and centrality strength (rss = .37-.86), but weaker similarities in network structure (rss = .36-.66) and centrality (rss = .04-.54) between clinical and nonclinical samples. Global strength (i.e., connectivity) did not significantly differ across all 5 networks and few edges (0-5.5%) significantly differed between networks. Specific metrics of similarity indicated that, on average, approximately 80% of edges were consistently estimated within and between all 5 samples. The most central symptom (i.e., dysphoria) was consistent within and across samples, but there were few other matches in centrality rank-order. In sum, there were considerable similarities in network structure, the presence and sign of individual edges, and the most central symptom within and across internalizing symptom networks estimated from nonclinical samples, but global metrics suggested network structure and symptom centrality had weak to moderate generalizability from nonclinical to clinical samples. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Treating Adults With Complex Posttraumatic Stress Disorder Using a Modular Approach to Treatment: Rationale, Evidence, and Directions for Future Research

ICD-11 complex PTSD (CPTSD) is a new condition, and, therefore, there are as yet no clinical trials evaluating interventions for its treatment. In this paper, we provide the rationale for a flexible multimodular approach to the treatment of CPTSD, its feasibility, and some evidence suggesting its potential benefits. The approach highlights flexibility in the selection of empirically supported interventions (or a set of interventions) and the order of delivery based on symptoms that are impairing, severe, and of relevance to the patient. The approach has many potential benefits. It can incorporate the use of interventions for which there is already evidence of efficacy allowing the leveraging of past scientific efforts. It is also consistent with patient-centered care, which highlights the importance of patient choice in identification of the problems to target, interventions to select, and outcomes to monitor. Researchers on modular treatments of other disorders have found that, compared to disorder-specific manualized protocols, flexible multimodular treatment programs are superior in resolving identified problems and are associated with greater therapist satisfaction and reduced patient burden. We briefly identify types of interventions that have been successful in treating trauma-exposed populations as well as emerging interventions that are relevant to the particular problems associated with exposure to complex trauma. We conclude with examples of how such treatments can be organized and tested. Research is now urgently needed on the effectiveness of existing and new intervention approaches to ICD-11 CPTSD treatment.